1. Opioid Use and Abuse: Pregnancy and Beyond
Catherine Brockmeier DO
Catherine Brockmeier DO

2. Disclosures No financial disclosures.
Thank you to Dr. Cresta Jones, Division of Maternal-Fetal Medicine at the University of Minnesota for sharing her research.

3. Objectives Understand the basics of the US opioid crisis.
Screen for and counsel female patients on opioid use.
Optimally management patients with opioid use disorders in pregnancy.
Perform best practice opiate prescribing.

4. The Opioid Epidemic: statistics
hhs.gov/opioids

5. Opiate use – United States
650,000 opioid prescriptions dispensed daily
3900 initiate nonmedical prescription opioid use daily
580 initiate heroin use daily
240 million prescriptions annually:
Every US adult – 5 mg hydrocodone every 6 hours for 45 days
hhs.gov\opioids

6. Opiate use – United States
5% of the world population…..
2014, only diagnosed cases, only 25% individuals actually seek treatment. Cost treatment, lost productivity, crime and deaths due to overdose
March 2015

7. Opiate use – United States
5% of the world population…..
…...80% of the world’s opiates!
2014, only diagnosed cases, only 25% individuals actually seek treatment. Cost treatment, lost productivity, crime and deaths due to overdose
March 2015

8. Opioid Use Disorder
Pattern of opioid use characterized by tolerance, craving, inability to control use and continued use despite adverse consequences.
Unsuccessful efforts to cut down and subsequent social problems
DSM-5
Mild, moderate, severe

9. Women & Opiate use Childbearing age:
1/3 prescribed opiate in last year
Similar rate in pregnancy
MMRCs identified substance use as major risk factor for pregnancy associated deaths
Ailes et al., 2015; Desai et al., 2014; SAMSHA 2013 national survey, HHS , 2014.

10. Opioid Use in Pregnancy
Medical care
Ensure opioids indicated
Highlight alternatives (PT, exercise, acupuncture, nonopioids)
Review risk/benefits
Utilize PDMP
Pregnancy not a reason to avoid treating acute pain because of concern for opioid misuse or NAS
Opioid misuse
Untreated opioid use disorder

11. Pregnancy complications
Maternal Complications
Fetal Complications
Infection – HIV, Hepatitis B/C, Tb, STIs
Poor fetal growth
Injury and overdose
Preterm birth
Death
Infectious exposures
Neonatal opiate withdrawal

12. NAS or NOWS

13. Benefits of treatment Improved prenatal care Improved birthweight
Decreased preterm birth
Improved treatment retention
Improved engagement in parenting
Improved maternal custody
Fullerton et al.2014; Jones HE et al., 2012, 2008

14. Treatment in pregnancy
Methadone
Buprenorphine

15. Methadone v. Buprenorphine
Daily observed therapy
Preferred with polysubstance users
Higher retention (78%)
Higher overdose risk
Equal NAS
Longer NAS treatment
Safe with breastfeeding
Exposed infant safety
Outpatient treatment
Need withdrawal to start
Increased diversion
Lower retention 58%
Lower overdose risk
Equal NAS
Shorter NAS treatment
Safe with breastfeeding
Limited infant data
Adapted from ACOG Executive Summary, July 2017

16. Alternatives Buprenorphine/naloxone duotherapy Abstinence, withdrawal
Limited data, use in some centers
Abstinence, withdrawal
Intensive inpatient/outpatient therapy
High relapse rate
Naltrexone (Vivitrol)
Limited safety data
Pain control concerns

17. Optimal pregnancy care
Universal screening
Antepartum care
Peripartum care
Postnatal care
Contraceptive counseling

18. Universal Screening Wright et al, 2016 Why to screen everyone
More common than CF, GDM and Anemia
National survey in pregnancy:
10% use alcohol
15% use cigarettes
5% nonprescribed/illicit substance
Increased adverse outcomes
More common than CF, gestational diabetes, anemia
Wright et al, 2016

19. Universal Screening ACOG 2017 ACOG Committee Opinion 711
“Should be part of comprehensive obstetric care and should be done at first prenatal visit.”
“Routine screening for substance use disorder should be applied equally to all people, regardless of age, sex, race, ethnicity, or socioeconomic status.”
ACOG 2017

20. Universal Screening Overwhelmed providers Inadequate training
Question of clinical utility
Fear of mandatory reporting
Uncertainty for referrals
Inadequate reimbursement
More common than CF, gestational diabetes, anemia
ACOG 2008; Wright et al, 2016

21. SBIRT

22. SBIRT Wright 2016 First visit, each trimester with past use
Validated instrument or standardized interview questions
Preferred method
Nonjudgmental and open ended questions
Urine toxicology should not replace
Not routine
Performed only with consent/mandatory reporting
May not detect all substances
False positive
Wright 2016

23. Referral to treatment Know what is out there Local resources
SAMHSA website
Consider training

24. Antepartum care Prenatal counseling Fetal anomalies
Minute increase in absolute risk of birth defects
Similar to general population
Fetal growth restriction
Preterm birth
Reddy 2017

25. Antepartum care Other screening Infection – STIs, HIV, hepatitis, Tb
Additional medication/substance use
Tobacco
Intimate partner violence
Comprehensive mental health
30% with concurrent mod to severe depression
40% develop postpartum depression
Comprehensive social assessment
Poor nutrition
Lack support system
Reddy 2017, Akerman 2012, Winklbaur 2009

26. Antepartum care Evaluation of fetal growth
If antepartum surveillance, 4-6 hours after treatment
Prenatal consultations
Anesthesia, pain management, peds, MFM, social work, lactation
Reddy 2017

27. Peripartum care Staff preparation
Continue with substance treatment in labor
Early regional anesthesia
Avoid nubain, stadol
Can precipitate withdrawal
Alternative pain management
Reddy 2017

28. Postpartum care Cesarean section – 50-70% opioid increase
Encourage lactation, rooming-in
Coordination with discharge meds
Coordination with social services
Follow up– relapse, depression
Reddy 2017

29. Responsible prescribing – after delivery
Structured interview, 720 women
Cesarean delivery
2 weeks after d/c
85.4% filled opioid prescription
Median dispensed #40 (30-40)
Median used #20 (8-30)
Leftover #15 (3-26)
95% has not disposed of extra
Elective or unplanned cesarean delivery
Bateman et al, 2017

30. Responsible prescribing – after delivery
Prospective observational study
All cesarean deliveries
Post op day 1-2; 14
Weekly contact until use cessation
Mean use 8 days (6-13d)
75% with unused tablets when stopping
Median 10 tabs (5 mg oxycodone)
63% stored unlocked location
Higher use = smokers, high in hospital use
8 week study period, excluded c-hyst, ICU admit or chronic opioid use, phone or follow up per patient preference
Osmundson et al 2017

31. Responsible prescribing – after delivery
Shared decision-making session before discharge
Patterns of pain
Expected outpatient use
Risk/benefits of use
Disposal and refill information
Mean number of pills chosen 20 (15-25)
50% reduction in standard 40 pill dosing
Manage expectations and provide education!
Tablet based decision aid
Prabhu 2017

32. Responsible prescribing – after delivery with breastfeeding
ACOG Practice Advisory on Codeine and Tramadol for Breastfeeding Women (April 27, 2017)
FDA strengthens warning that BF not recommended with tramadol/codeine
Active metabolites
Potential for serious adverse effects in infants  resp. depression and excessive sleepiness
Especially in CYP2D6 “ultra-rapid metabolizers”(4-5% of US pop.)
ACOG, SMFM and ABM recommend
Consider opioids other than codeine/tramadol
AAP says butorphanol, morphine and hydromorphone preferred
If codeine containing use, discuss risks/benefits with family
ACOG 2017

33. Responsible prescribing – after delivery (ACOG)
Committee Opinion No. 742
Multimodal and individualized approach is best
Parenteral/oral opioids should be reserved for breakthrough pain
Proper discussion of risks/benefits if codeine-containing
ACOG 2018

34. Responsible prescribing – after delivery (ACOG)
Vaginal delivery
NSAIDs + Acetaminophen
NSAIDs (scheduled) + Acetaminophen (scheduled) + Mild Opioid (prn)
Decreased opioid use and consistent analgesia
Cesarean section
Neuraxial opioids
NSAIDS + Acetaminophen + Opioids (oral preferred)
PCA if requires parenteral opioids
Consider TAP block, Exparel
Which opioids?
Oxycodone/hydrocodone metabolized by CYP2D6
More potent metabolites
Hydromorphone not metabolized by CYP2D6

35. UTILIZING THE PDMP
Patient history of controlled substance prescriptions
Currently available in 49 states
Prior/ongoing opioid prescriptions
Dangerous combinations increasing overdose risk
Most cover opiates, benzodiazepines, stimulants and tramadol

36. South Dakota Prescription Drug Monitoring Program
All queries must be done through . All submissions must go to .

38. Conclusion Opiate use disorder = epidemic Universal screening
Know the options
Consider increased pregnancy care
Practice best prescribing

39. References
Patrick et al. Increasing incidence and geographic distribution of neonatal abstinence syndrome: United States 2009 to J Perinatol 2015 Aug; 35(8):650-5.
Patrick et al. Neonatal abstinence syndrome and associated health care expenditures: United States, JAMA 2012 May 9;307(18):
Ailes EC et al. Opioid prescription claims among women of reproductive age – United States, MMWR Morb Mortal Wkly Rep 2015;64:37-41.
Desai RJ et al. Increase in prescription opioid use during pregnancy among Medicaid-enrolled women. Obstet Gynecol 2014;123:
Chasnoff IJ et al. Validation of the 4Ps Plus Screen for substance use in pregnancy. J Perinatol 2007;27:744-8.

40. References
Wright et al. The role of screening, brief intervention, and referral to treatment in the perinatal period. Obstet Gynecol 2017;130:10-28.
Fullerton et al. Medication-assisted treatment with methadone: assessing the evidence. Psychiatr Serv Feb 1; 65(2):
Jones HE et al. Methadone and buprenorphine for the management of opioid dependence in pregnancy. Drugs 2012 Apr 16;72(6):
Jones HE et al. Methadone maintenance vs methadone taper during pregnancy: maternal and neonatal outcomes. Am J Addict 2008; 17(5):
American College of Obstetricians and Gynecologists. Alcohol abuse and other substance use disorders: ethical issues in obstetric and gynecologic practice. ACOG Committee opinion no Obstet Gynecol June 2015.

41. References
Osmundson SS et al. Postdischarge opioid use after cesarean delivery. Obstet Gynecol July 2017, 130(1): 36-41
Bateman BT et al. Patterns of opioid prescription and use after cesarean delivery. Obstet Gynecol July 2017, 130(1);
Pradhu M et al. A shared decision-making intervention to guide opioid prescribing after cesarean delivery
Meyer M et al. Intrapartum and postpartum analgesia for women maintained on methadone during pregnancy. Obstet Gynecol 2007; 110:
Meyer et al. Intrapartum and postpartum analgesia for women maintained on buprenorphine during pregnancy. Eur Jl Pain 14; 2010:

42. References
Manchikanti L et al., Responsible, safe, and effective prescription of opioids for chronic non-cancer pain: American Society of Interventional Pain Physicians (ASIPP) guidelines. Pain Physician 2017 Feb;20(2S): S3-S92.
Moore RA et al., Single dose oral analgesics for acute postoperative pain in adults. Cochrane Database of Systematic Reviews, Sept 2015.
CDC Guideline for Prescribing Opioids for Chronic Pain – United States Dowell D et al. JAMA 2016 Apr 19/315(15):
Wightman R et al. Likeability and abuse liability of commonly prescribed opiates. J Med Toxicol 2012; 8:
Winklbaur B et al. Association between prenatal tobacco exposure and outcomes of neonates born to opioid maintained mothers. Eur Addict Res 2009; 15(3):
Akerman et al. Treating tobacco use disorder in pregnant women in medication- assisted treatment for an opioid use disorder: a systematic review. J Subst Abuse Treat: 2015 May; 52:40-47.